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Trauma Treatment |
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Trauma Treatment |
Abstract
Although the processes of memory and recall are known often to be affected by critical incidents, they are barely mentioned, if at all, in the training of operational emergency personnel. Indeed they hardly feature in the training of health professionals who work in a variety of settings, and they do not appear much even as key words in the relevant research area. The omission came sharply into prominence not long ago in the High Court in New Zealand when a discourse on memory was invited from expert witnesses, and for the very first time a jury accepted 'flashback' and post traumatic stress disorder as a defence of provocation to a charge of murder. The topic was taken further during a stress/trauma assignment and two referrals that will be described. The aim is a) to draw parallels for the consideration of trainers, peer-supporters, and emergency workers, b) to underline the importance of bringing traumatic memories into the viable mainstream of memory, and c) to suggest that various forms of critical incident stress management do more than extend camaraderie and give occupational and social support.
The proposition is that no matter how wide the range of presenting problems, and how different the given circumstances, the underlying purpose of peer-support, defusing, debriefing, counselling, and psychotherapy, is to prevent the memory of traumatic events from becoming fixed, inaccessible, and troublesome. It has some empirical and experiential support, and its rationale can be defended sufficiently to justify its use. It can also be explained in simple terms to those affected, without recourse to the undesirable ambiguity which previously enshrouded many kinds of intervention. But it has to be admitted that suitable methods and techniques for the precise validation of the memory-work have yet to be developed.
The need to give memory greater priority arose recently in connection with four referrals - the first of which will be outlined here, before sketching the underlying operations of memory, and its exemplification with the other three. The sequel is presented, not because the nature and consequences of neglecting trauma from civil emergencies are likely to be quite as severe as in the case of the killing, but that they might be somewhat comparable. Many emergency personnel have had friends and colleagues who indulge in denial, wishful-thinking, and avoidance rather than face painful memories arising from work-related trauma. Many therapists have come to reflect on the memories of suffering endured by refugees seeking asylum abroad (Waxler-Morrison, Anderson, & Richardson, 1990), by minority groups in their own countries (Marks & Worboys, 1997), and by people like Jan Ruff-O'Herne (1994) who, as a Dutch internee in Indonesia, reactivated her experience of being enslaved in prostitution by the Japanese some 50 years before. Then, following commemorative programmes and publications of wartime reminiscences (e.g. Parr, 1995; The Psychologist, 1997; Challinor, 1998), many will have thought that had there been simple debriefing programmes available for the military long ago, the burden of tragic memories on veterans and their families might not have been so heavy.
The vexed question of 'repressed memory' - i.e. the argument that long delayed recall can be prompted, induced, and influenced unduly by determined helpers at the expense of truth and justice - will be left aside for consideration elsewhere (cf. Gow, this volume). That debate rages on many fronts, and those who wish to follow the arguments could begin with the special edition of the Journal of Traumatic Stress (1995), and consult Hewson (1996), Brandon, Boakes, Glaser, & Green (1998) and Pendergrast (1998) for an overview. For the record, although Pope (1996) described memory as 'fallible, malleable, and suggestible', by 20 December 1997 Cheit (1998) had compiled a 'Recovered Memory Archive' of no less than 35 cases, each of which had satisfied the criteria of being verifiable through strong corroborative evidence from either an admission, or testimony from other victims and eyewitnesses, or relevant documentation, or significant circumstantial evidence, or from a combination of such.
It was only while he was in prison on remand for the charge of murder that his presenting symptoms were regarded by the prison doctor as typical of PTSD: i.e. marked sensations of re-experiencing a traumatic event, avoidance, and hyperarousal (American Psychiatric Association, DSM IV, 1994). But he was reluctant to discuss the matter with the visiting psychiatrist, and needed persuasion before mentioning it even to his lawyer.
The arguments for both sides were well canvassed during two long trials. At the first trial the defence called expert witnesses to comment on a) the clinical validity of the facts as presented, and b) the academic aspects of the psychophysiology of stress and trauma., and c) the processes of memory. The Crown chose not to call its own experts in rebuttal, but in a typical adversarial manner to challenge vigorously the evidence that was given by the defence. The jury returned a verdict of guilty of murder, but later the Court of Appeal ordered a retrial on procedural points.
Subsequently the second trial covered much of the same ground as before, except for additional evidence provided for the Defence from a Forensic Psychiatrist and by the original abuser. In between trials the Defence had located the man and had him interviewed by the Police. He admitted committing the sexual assaults, made mention of others he had committed at the time, and said that he had just pleaded guilty in another Court to three representative charges relating to them. He went on to acknowledge from photographs his facial and physical resemblance to the deceased in the present case. He agreed that the places in which they both lived were similar in size, furnishings, and ambience. He described his technique for the initiation of sexual advances, (which proved to be similar to that reported of the deceased), and he agreed that he had used threats and intimidation to prevent his young victims from telling anyone what he had done to them.
In the event the second jury found the accused not guilty of murder but guilty of manslaughter - a charge to which incidentally the defence had offered to plead from the outset two years before - and the judge imposed a sentence of five years imprisonment. Later in another Court the original abuser was sentenced to two and a half years imprisonment on three representative charges.
With the wisdom of hindsight, it is profitable to think that had the accused been able to talk about his traumatic experience to either his parents, his teachers, the school psychologist, or someone else as he grew up, the outcome might well have been different. He might then have been able to loosen the ties with which he had bound those memories, put the memories into some perspective, and profit from them by being more knowledgeable about human behaviour - and the victim of the killing might still have been alive. Fortunately he showed early indications of appropriate remorse after the trial, without experiencing further blockages of memory and without presenting a pattern of psychological symptomatology as before. At the last report he had completed his sentence, had a steady girl-friend, and was holding a steady job.
In the normal course of events, memory serves many purposes. It gives a sense of personal identity and cultural membership, and provides an accessible repository for acquired information and learned responses. It copes with prospective events as well as the retrospective - i.e. the retentive memory of plans made for future enactment and of strategies to execute them, as well as the recording of those that have occurred in the past. For convenience the time zones are divided into the three periods of immediate, short-term, and long-term. In summary, memory is the central fluid capacity for receiving, processing, storing, and retrieving sensory input with whicha passage is negotiated through life (Wieten, 1995, pp 255-293).
n abnormal circumstances memory can be used as a lifeline to ensure sanity and survival, as some captives in solitary confinement have shown. For example, when Edith Bone (1957, pp. 109-111) was held for seven years in solitary confinement by the Hungarians on suspicion for being a spy, she kept herself psychologically intact by going for 'walks' in her cell to visit the major European cities she had known. In this way she used her memory to recall the precise details of buildings, monuments, and streets. She also 'walked' a certain distance each day back to England, four times by different routes. Then she made an inventory of the words she knew in six languages - and contrived an abacus from bread crumbs and pieces of sorghum plucked from the head of a broom to help her keep count of the number. Similarly, Nien Cheng (1993, ch. 5) relied on her memory during her six-and-a half years in solitary confinement in China to keep herself mentally intact, to come to a better understanding of herself with regard to the Mao political system, and to confront her captors with her conclusions when they interrogated her.
Psychological trauma features in profound emotional states of dissociative amnesia, and it can be symptomatic of identity disorder, fugue states, and disorders of either acute stress, or posttraumatic stress (DSM IV 1994, pp 424-432, & pp 477-491). In the latter case, without evidence of prior pathology, memory is blocked either by the spontaneous regurgitation of distressing experience, or its release by outside prompting. The raw sensations of the trauma are said to remain unmodified in the non-declarative part of memory (Reber, Knowlton, & Squire, 1996). Being isolated from the influence of the declarative processes, the sensory input is stored at a somatic state of arousal where it generates a series of neuro-biological behavioural changes. Those changes affect the critical thresholds of response to perceived external threat, and induce psychophysiological concomitants of re-experiencing the event (Coleman cited in Cameron, 1994; van der Kolk,1994). In one case reported recently, such psychic trauma was found to have affected neuronal tissue, brain metabolism, and cognitive performance (Markowitsch, Kessler, Van der Ven, Weber-Luxemberger, Albers, & Heiss, 1998).
The loss of memory for traumatic experience, unlike the loss of memory for a variety of items of everyday information, cannot easily be discerned from responses to specific psychometric tests. Not only is the definition of trauma perceptually unique to the individual, but trauma has a strong unconscious component that is generated by the need for self-preservation and the avoidance of further harm. The protective component sets limits on topics of conversation, restricts friendships, and makes those affected avoid places and situations similar to those which gave rise to the non-declarative memories - whether they be painful, terrifying, or even reminders of culpability for which disclosure might bring penalty. It prevents the memories being processed into a guidance system for further use, and requires constant vigilance and the diversion of considerable emotional energy to ensure that they do not reach the light of day. It constitutes unusable baggage that has to be carried at a continuing cost throughout life until it can be opened and appraised safely.
The weight of the baggage is often such as to induce a preoccupation with either the trivia or the bizarre, which through body-language, drawings, dreams, involuntary slips of the tongue, and over-assertive behaviour, give the shrewd observer a hint of the classified secrets (Freud, 1948 edn.). Sometimes a glimpse of the unprocessed memories appears unexpectedly through flashbacks, when a chance remark, sight, smell, sound, taste, and touch, triggers the pattern of sensory information that has long been held at bay.
Flashbacks, or the unexpected and unwelcome reliving of trauma, are sometimes seen in a wide range of victims in different categories of disaster, including those in the more vulnerable and overburdened of emergency services They can formally be described as:
'episodes of visual distortion, time expansion, physical symptoms, loss of ego boundaries, or relived intense emotions, lasting usually a few seconds to a few minutes, but sometimes longer......as a rule (they) are mild, often pleasant, but occasionally they turn into repeated frightening images or thoughts resembling..the acute anxiety symptoms that start after a near escape from death in combat, an accident, or a natural catastrophe'
(Kaplan, Freedman & Sadock, 1980, p 1627, p 2102).
However, it has to be said that flashbacks need to be thoroughly documented, otherwise if will be difficult to refute Frankel's (1994) assertion that their content 'appears to be at least as likely to be a product of imagination as it is of memory'.
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